Common Medication Delivery Errors & How to Avoid Them
By Team Altus
Published Dec 11, 2018
| Updated Sep 14, 2022
| 5 min read
Between the med room and a patient’s room, nurses are faced with numerous distractions. Between interruptions, searching for the correct equipment, and offering a positive point-of-care experience; there are simply too many obstacles preventing clinicians from delivering medication fast and effectively to their patients.
These barriers don’t just slow down the medication delivery process, they open the door for a host of errors. With medication-related errors contributing to more than 7,000 deaths in the U.S. annually, it puts it at the 3rd leading cause of death in the United States right under heart disease and cancer.
In order to lower these numbers and find ways to streamline the medication delivery process, we looked at the most common medication delivery errors and created a workstation to alleviate those errors.
Common medication delivery errors
In healthcare, patients rely wholly on the clinicians helping them. This includes receiving and administering their medication properly. Medication delivery errors cause more than just giving the wrong medication to the wrong patient. Of these errors, they lead to more than adverse effects for patients. They can also cause misplaced medication, increased cost, over or under-medicating, and over-complicating standard regulatory requirements.
In order to keep these issues from happening, watching for the most common medication delivery errors and preventing them from happening is imperative. The most common medication delivery errors include:
Oral and written miscommunication
Insufficient time to counsel patients
1. Oral and written miscommunication
Oral and written communication is the first step in the medication delivery process. When a nurse begins the medication delivery process, they start by packing up their medicine trolley with the various medications they need for the day. While doing that they have to try to decipher illegible handwriting and hope they interpreted it correctly.
Interpreting handwriting can cause challenges in picking the correct medication when there are similar medication names. Nurses have to make quick decisions. Oral miscommunication follows the same trends. A nurse may only get a short description of a medication, or a few broken words as the prescriber moves from room to room.
Then it is up to the nurse to interpret what was said while they pack the medication for their rounds. If miscommunication was too apparent and nurses accidentally get it wrong, it can harm a patient or cause more confusion throughout the day.
Preventing oral and written miscommunication is easy with one single step: slowing down. When a nurse is given a medication order, before jetting off to the next patient, allow a moment to ask a question. They can recite back what they read or heard, or use the extra few seconds to confirm the order. Taking the extra time at the beginning of the medication delivery process saves time and potential issues later.
2. Overwhelming workload
Nurses shoulder stressful workdays coupled with long shifts. In any one shift, a nurse can walk between 4-5 miles plus the weight of their workstations. It becomes exhausting, and after so many hours, mistakes will be made. In nurses who have worked over 12.5 hours 58% of the reported errors, were associated with medication administration.
The long hours coupled with the expectations of proper bedside care and medication sorting and delivery are enough to produce mistakes. Preventing an overwhelming workflow keeps medical errors from occurring.
Taking steps to ensure nurses perform self-care is one route to preventing errors. Self-care helps calm nurses and allows them to feel rejuvenated before a shift so they can perform their tasks to the best of their ability. Hospitals can also choose to use 12-hour shifts sparingly and offer ergonomic workstations. Not expecting nurses to consistently work 12 hours keeps nurses from feeling fatigued and potentially making a mistake. Ergonomic workstations, like the ones Altus designs, create a comfortable workplace for nurses so they can distribute medication without feeling the strain on their bodies from transversing an entire hospital.
3. Name confusion
When it comes to gathering medication for an entire hospital floor at one time, nurses are bound to encounter repeated names. Whether it be first, last, or both, patients will have overlapping names that can cause confusion. If a nurse misses a letter or a small detail, they could be delivering the wrong medication to a patient.
The two main ways to avoid having this happen in your hospital are by having two forms of identification and having nurses slow down. Nurses are in a hurry to pack up their medicine cart so they can deliver to their floor, but taking an extra few seconds to double-check the right medication is in the right spot can keep a patient from receiving the incorrect medicine or dose.
In addition, having two forms of identification adds an extra layer of security. When nurses are checking the medicine before beginning distribution the second form of identification confirms they have it in the right spot and not for another patient. This ensures everything is in the right spot when they lock the medication delivery module’s drawers and start the delivery process.
4. Insufficient time to counsel patients
In healthcare, the staff is being pulled in several different directions at once. With nurses spending only 32.97% of their day with patients, and physicians spending even less, they don’t have sufficient time to talk through every possible avenue, and in some cases, barely have time to distribute medication to their floor before they’re pulled away. In these cases, patients can potentially receive a medication they’re allergic to, not receive the right dose, or receive the wrong medication altogether.
To make the medication delivery process smooth and easy for nurses, having a workstation built for medication delivery is the best avenue. These workstations on wheels are built to store medication securely and organize every medication so nurses can have everything clearly labeled lowering the chance of mistakes when they don’t have a lot of time.
An additional way for healthcare professionals to work around not having sufficient time with patients is by implementing a series of double-checking. Before administering any medication, nurses should: double-check the medication label, check the order, check and confirm the last time they received their medication and what the requirements are, document the new administration, and check back in at the end of their rounds to check for reactions. This series of checks allows nurses to make sure they’re giving the correct medications to patients and makes the process easier on them from start to finish.
Medication delivery is a time-consuming process that can allow mistakes if not well thought out. The process can be made easier by hospital systems, and common medication delivery errors can be avoided, making a better experience for nurses and patients alike. The addition of a medication delivery wow cart can transform the way nurses work, and create a better workflow as well. Learn more about Altus’ medication delivery cart and how it can help your hospital’s medication delivery by contacting us today.